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Research Prospectus
Food Allergy Nutritional Management
Introduction
Food allergies affect up to 8% of American children and up to 5% of American adults.¹ ²
These numbers have increased, possibly tripled since 1997.¹ The treatment for all food allergies
is complete avoidance of the offending food.³ Learning to avoid allergenic foods can be
daunting for patients and families. Accidental exposures can cause life-threatening reactions, so
strict avoidance is a must. However, when foods are eliminated from the diet, the patient may be
at risk for nutrient deficiencies, if careful diet planning does not occur.³ Nutrition education is
necessary in this population in order to prevent accidental exposures and also to prevent nutrient
deficiencies.⁴ The best resource for nutrition education is a registered dietitian (RD) who is
trained in food allergy education.³ ⁴
Background
A registered dietitian is an important member of the healthcare team when treating food
allergies.⁵ A dietitian will provide education for the patient that outlines how to avoid the
allergen(s), how to read food labels and alternative names for allergens. She will also monitor the
patient for any nutrient deficiencies related to eliminating a food or multiple foods from the
diet.⁵ However, not all RDs have specific training in the area of food allergy treatment. It is
important to determine if there is a lack of knowledge of food allergy treatment among RDs.
Research Question
Preventing adverse reactions and maintaining adequate nutrition are important results of
proper nutritional management of food allergies. In relation to the above topic, the question
must be answered, “What level of knowledge about the dietary management of food allergies do
registered dietitians working with adults in the United States possess?” Previous studies have
focused primarily on pediatric RDs.⁶ ⁷ ⁸ Since food allergies can be diagnosed at any age, it is
important to understand the level of knowledge RDs working with adults have. For this study,
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age 18 years and older will be considered an adult patient. This is based on the age the Centers
for Disease Control and Prevention (CDC) has used as a cutoff in statistics of the US. studies.⁹
If registered dietitians working in adult populations are not properly trained, patients may not
have the highest level of care. The hypothesis: Registered dietitians working with adults will
self-report moderate or less than moderate proficiency in the nutritional management of food
allergy.
Literature Review
There have been several studies performed in recent years addressing the educational
needs of RDs in food allergy nutritional management.⁶ ⁷ ⁸ The studies all vary slightly from
one another in the location of RDs, whether dietetic students were also surveyed, and if pediatric
and/or adult RDs were surveyed. Method of survey administration also varied between
Internet-based and paper-based. Overall, the studies found only moderate levels of knowledge in
the nutritional management of food allergies among the various groups of RDs.⁶ ⁷ ⁸
Groetch et al found that pediatric RDs working with food allergies, self-report a moderate
level knowledge in the area of food allergies. ⁶ Researchers utilized an internet-based survey of
pediatric registered dietitians to obtain their data. Pediatric RDs were the subject of the study
since food allergy diagnoses are more common in childhood. Most of the education in food
allergy management was self-taught. The survey also looked at preferred methods of further
instruction. They found that internet-based handbooks and patient handouts were the most
selected options. Limitations to the study include the low response rate, with only 17.5% of
pediatric RDs responding, and the fact that a survey may have a self-selection bias. Also, this
was an internet-based survey, which may indicate those who responded are more technologically
inclined.
Building on Groetch et al’s research is another study titled: Food allergy competencies of
dietitians in the United Kingdom, Australia and United States of America.⁷ This study took
Groetch et al’s research and survey tool and adjusted it slightly to be used in the United
Kingdom and Australia. This survey was not only performed on pediatric dietitians, it included
adult RDs as well. The findings of Maslin et al were similar to Groetch, but they were able to
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see slight differences between countries. Australian and UK RDs indicated food allergy
education during dietetic training, at a higher rate than US-based dietitians. Overall, they found
a need among dietitians to increase their knowledge base about food allergies. This study has
some limitations. The original work by Groetch et al only surveyed pediatric RDs, while the
Australian and UK versions surveyed both pediatric and adult RDs, so it was not a direct
comparison. Similar to Groetch et al, this survey may also have self-selection bias and may have
excluded those less comfortable with technology.
Ginis et al performed a study in Turkey focusing on the level of knowledge of dietitians
and dietetic students in the management of children with food allergy.⁸ This was a paper-based
survey with an 81.3% response rate. In this study, the participants did not know the nature of the
survey in advance. This is important to note because the previous two studies were sent via
email and may have excluded those less inclined to use technology. This survey was
paper-based and since the participants did not know the nature of the study in advance, it may
have had less self-selection bias. This study does not have that limitation, however, it did have a
smaller sample size than the other two studies. This study had similar findings: that RDs have
only a moderate knowledge base in the area of food allergy nutritional management.
Taking the research one step further, Reeves et al performed a case study showing the
improvement in knowledge after a one-day course related to cow’s milk allergy in dietitians in
the UK.¹⁰ In this study, participants completed a pre-course test, measuring knowledge of cow’s
milk allergy. They then attended the day-long course and completed a post-test of the same
material, and again one month later. The researchers found there was a significant improvement
in scores after the course and one month later. This shows the participants retained knowledge.
Since this was a case study, it was small, which is limiting. Also, participants were not tested
again, after the one-month post-course, to check for longer-term knowledge retention.
A study published in 2016, looked at the celiac disease patient’s views regarding
expectations from a dietitian.¹¹ Patients were interviewed regarding their experiences with
dietitians upon celiac disease diagnosis and any follow-up appointments. While celiac disease is
not a food allergy, the treatment is also a strict avoidance of the food and nutrient deficiencies
are often seen in this population as well.¹² Findings from the focus group include greater
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satisfaction of patients when the dietitian had a high level of expertise. This was a focus group
and therefore qualitative in nature, making it unlike the other studies. However, it gives valuable
insight into what a patient expects from her dietitian.
Methodology
Study Design
This study will use the survey validated and used by Maslin et al.⁷ By using the same
survey in this study, data can be compared more accurately between the two, as there is currently
no information regarding US adult RDs knowledge of food allergy nutrition management.
Participants will be registered dietitians in the US. The survey will ask for the dietitian to
indicate his or her proficiency/knowledge level in fourteen areas. ⁷ The survey will use a Likert
scale, with answer choices being: not at all proficient, low, moderate, high, and not applicable to
my practice.⁷ The survey will also include questions to assess where knowledge of food allergy
was obtained by the professionals, and in what manner they would like to increase their
knowledge.⁷ Demographic information including years in practice, practice setting, allergy
training will also be reported. See attached survey. It is expected that these results will show a
moderate or less than moderate level of self-reported knowledge of food allergy nutritional
management.
Data Collection
The survey link will be sent via email to registered dietitian members of the Academy of
Nutrition and Dietetics. The email will include information about the study being performed and
the importance of obtaining this data as well as informed consent. The contact information of
the researcher will also be displayed. The email will also highlight the fact that there is complete
anonymity with regards to the survey.
The data obtained from the completed surveys will be explained using descriptive
statistics since the goal is to understand the current level of knowledge possessed by registered
dietitians.¹³ The demographic information will be presented in percentages to show how long
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subjects have worked as registered dietitians, type of practice setting, the percentage of patients
with food allergies and how they obtained their food allergy training.
Once the descriptive data is compiled, the researcher will look at inferential statistics to
see if there are any correlations between demographics and levels of knowledge for the various
categories. For the food allergy competencies, Pearson correlations can be calculated for the
individual questions with respect to the length of practice and percentage of patients that have
food allergies.⁷ It is possible that those practitioners who see more patients with food allergies
would have greater knowledge of food allergy management.⁶ There will be 14 questions related
to the level of food allergy management knowledge.⁷ Each question will be assessed
individually, with percentages given in each possible answer: not at all proficient, low, moderate,
high, or not applicable to my practice. If greater than 50% is indicated in moderate or less than
moderate, the hypothesis will be supported.⁶
Ethically speaking, it is important to select participants from a group of people that would
benefit from the research. This falls under the Belmont Principle of justice.¹⁴ By selecting
registered dietitians who practice in clinical dietetics, this principle is addressed, as these are
professionals who will benefit from the results of research done in this area. Other possible
ethical concerns may be the psychological well-being of participants. Upon completing a
survey, a participant may become particularly aware of their lack of knowledge in the area of
food allergy treatment and if their sense of self-efficacy is not strong, may feel some
psychological detriment upon this realization. This would be considered when attempting to
minimize the psychological risks as indicated in the Belmont Principle of Beneficence.¹⁴ When
considering the Belmont Principle of Respect for Persons, it will be important to treat all
participants in the same manner. This includes keeping information confidential and also
approaching all participants in the same way and using the same survey for all.¹⁴
This research would likely be exempt from IRB review because it is a survey of adults
and the information collected will be anonymous and untraceable to the participant.¹⁴
Discussion
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The number of children and adults being diagnosed with food allergies continues to grow.
While food allergies are often diagnosed in childhood, more adults are receiving food allergy
diagnoses.¹⁵ Registered dietitians are the appropriate health care team member to provide
nutrition education and monitoring of nutrient adequacy in the diet.⁵ Current research in the US
has focused on pediatric dietitians knowledge of food allergy management. It is important to
also assess RDs working in all life cycle stages, since food allergies may occur and persist at any
age. A survey of US adult registered dietitians, will show the difference (or not) in these two
types of RDs. This information can be used to determine where to focus future food allergy
education in registered dietitian training.
Limitations
Self-reporting of knowledge relies on the participant to be truthful. It will be unknown
whether respondents give truthful answers. Also, it is important to remark that self-reporting in
itself may not be the most accurate measure of knowledge. Participants may over or
underestimate their actual knowledge of the subject. The Academy of Nutrition and Dietetics has
over 100,000 members¹⁶, giving a large population size. As of 2018, there were over 101,000
registered dietitians in the US. ¹⁷ The sample size will likely be much smaller, but having a large
starting population should help maintain the validity of the study. There is a chance for
self-selection bias in this study. Those who respond may have a greater interest in food allergy
management than those who do not, which may mean the sample is not indicative of all
registered dietitians. This will be an internet-based study, so those not comfortable using this
type of technology may not participate, further affecting results.⁶
Reliability
Data will be collected in the same way from all participants, via an internet survey. While the
survey will be identical for all participants, the conditions under which they complete the survey
may vary. This could potentially affect how a participant answers a question.
Error
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By surveying a large population group, the random error should remain low. Since the study will
use an internet-based survey there is a chance for some systematic error. The participants will
take the survey when they want and therefore outside influences could affect their responses
unbeknownst to the researcher.¹⁸
References:
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2. Dunlop JH, Keet CA. Epidemiology of food allergy.Immunol Allergy Clin N Am. 2018;
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3. Groetch M, Nowak-Wegrzyn A. Practical approach to nutrition and dietary intervention
in pediatric food allergy. Pediatr Allergy Immunol. 2013; 24:212-221.
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4. Canani RB, Leone L, D’Auria E. The effects of dietary counseling on children with food
allergy: A prospective, multicenter intervention study. J Acad Nutr Diet. 2014;
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Published May 2013. Accessed October 1, 2018.
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Accessed October 10, 2018.
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